Happy Charting

Information

Name *

Email *

Birthdate

Phone Number *

Today's Date *

Address

Address Line 1

Address Line 2

City

State

Zip

Personal Information

Height

Weight

Age

Occupation

Primary Physician

Name

Phone Number

How did you hear about us?

Contact Information

Home Phone

Work Phone

Other/ Cell Phone

Another person we may contact if needed:

Name

Relationship

Home Phone

Work Phone

Have you had the Covid Vaccination? (Yes or No) *

If yes, then on what date(s) and brand (Pfizer, J and J, Moderna)

What are your primary concerns for coming in for treatment?

List medications or food supplements you are taking. (General area of use is OK eg Diabetes meds)

List serious illnesses, accidents or surgeries (date).

How long has it been since you have had a complete medical exam?

Check illnesses that have occurred in blood relatives.

Diabetes

High blood pressure

Stroke

Heart disease

Kidney disease

Asthma

Hayfever

Migraines

Cancer

If cancer checked, what type?

Check symptoms you have or have had in the last year:

Depression

Difficulty in focusing

Dizziness

Mood Problems

Fatigue/ tiredness

Headaches

Loss of sleep/poor sleep

Loss of weight

Gain of weight

Check symptoms you have or had in the last year: MUSCLE/JOINT/BONES

Tremors

Swollen joints

Weakness

Cramps

Numbness

If other, please state:

If Phlegm checked, what colour?

CARDIOVASCULAR

Chest pain

Pain over heart

Poor circulation

Previous heart attack

Rapid/irregular heart beat

Swelling of ankles

SKIN

Boils

Bruise easily

Dry skin

Itching/rash

Sensitive skin

Sore won't heal

Unusual sweating

GENITOURINARY

Blood/pus in urine

Frequent or urgent urination

Inability to control urine

Urinary tract infection

Kidney infection/stones

Erection difficulties

Penis discharge

Prostate trouble

Night Urination

If Night Urination checked, # times?

Menstruation

Age at Menses

Length of Cycle (eg 28 days)

Duration of Cycle (eg 3-5 days)

Age at Menopause

# Pregnancies

# Births

Please check any that apply:

Vaginal Discharge

Hot Flashes

Vaginal Discomfort

Even if you are in menopause, answer the questions about how your cycle was.

Excessive menstrual flow

Menstrual pain

Clots

Irregular cycle

PMS

Could you be pregnant?

COVID-19 INFORMED CONSENT TO TREAT

I understand that the novel Coronavirus (COVID-19) has been declared a global pandemic by the World Health Organization (WHO). I further understand that COVID-19 is extremely contagious and may be contracted from various sources. I understand COVID-19 has a long incubation period during which carriers of the virus may not show symptoms and still be contagious.

I understand that I am the decision maker for my health care. Part of this office’s role is to provide me with information to assist me in making informed choices. This process is often referred to as “informed consent” and involves my understanding and agreement regarding recommended care, and the benefits and risks associated with the provision of health care during a pandemic. Given the current limitations of COVID-19 virus testing, I understand determining who is infected with COVID-19 is exceptionally difficult.

To proceed with receiving care, I confirm and understand the following:

- I understand my treatment may create circumstances, such as the discharge of respiratory droplets or person-toperson contact, in which COVID-19 can be transmitted.

- I understand that I am opting for an elective treatment that may not be urgent or medically necessary, and that I have the option to defer my treatment to a later date. However, while I understand the potential risks associated with receiving treatment during the COVID-19 pandemic, I agree to proceed with my desired treatment at this time.

- I understand due to the frequency of appointments with patients, the attributes of the virus, and the characteristics of procedures, I may have an elevated risk of contracting COVID-19 simply by being in a health care office.

- I confirm I am not experiencing any of the following symptoms of COVID-19 that are listed below:
*Fever
*Shortness of Breath
*Dry Cough
*Runny Nose
*Sore Throat
*Loss of Taste or Smell

- I understand travel increases my risk of contracting and transmitting the COVID-19 virus. I verify that I have NOT in the past 14 days I have not traveled: 1) Outside of the United States to countries that have been affected by COVID-19; or 2) Domestically within the United States by commercial airline, bus, or train.

- I am informed that you and your staff have implemented preventative measures intended to reduce the spread of COVID-19. However, given the nature of the virus, I understand there may be an inherent risk of becoming infected with COVID-19 by proceeding with this treatment. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective treatment and give my express permission to you and the staff at your offices to proceed with providing care.

- I have been offered a copy of this consent form.

I KNOWINGLY AND WILLINGLY CONSENT TO THE TREATMENT WITH THE FULL UNDERSTANDING AND DISCLOSURE OF THE RISKS ASSOCIATED WITH RECEIVING CARE DURING THE COVID-19 PANDEMIC. I CONFIRM ALL OF MY QUESTIONS WERE ANSWERED TO MY SATISFACTION.

Terms And Conditions

I HAVE READ, OR HAVE HAD READ TO ME, THE ABOVE COVID-19 RISK INFORMED CONSENT TO TREAT. I APPRECIATE THAT IT IS NOT POSSIBLE TO CONSIDER EVERY POSSIBLE COMPLICATION TO CARE. I HAVE ALSO HAD AN OPPORTUNITY TO ASK QUESTIONS ABOUT ITS CONTENT, AND BY SIGNING BELOW, I AGREE WITH THE CURRENT OR FUTURE RECOMMENDATION TO RECEIVE CARE AS IS DEEMED APPROPRIATE FOR MY CIRCUMSTANCE. I INTEND THIS CONSENT TO COVER THE ENTIRE COURSE OF CARE FROM ALL PROVIDERS IN THIS OFFICE FOR MY PRESENT CONDITION AND FOR ANY FUTURE CONDITION(S) FOR WHICH I SEEK CARE FROM THIS OFFICE.

I have read, understand and accept the Terms & Conditions. The information in this form is correct to the best of my knowledge. *

Informed Consent, Cancellation and Privacy Policies

I am here for evaluation by the Doctors of Oriental Medicine (DOM) at Community Acupuncture Albuquerque. I understand that the DOMs will utilize medical history plus physical examination to evaluate me. The DOMs may discuss treatment options and course of treatment with me. 

The DOMs may carry out the following treatments in this office: primarily acupuncture, but sometimes - moxibustion (heating of acupuncture points), electrical stimulation, therapeutic exercise, massage, Tui Na (oriental medical manipulation of the spine or other joints), drawing a few drops of blood, nutritional advice, the prescription of herbs, supplements, and other natural medicines, lifestyle advice, or other treatments. 

I understand that even naturally oriented procedures do carry some amount of risk. Needles are capable of causing bleeding, bruising, or extremely rarely lung or organ injury or infection. Adverse events are minimized when the clinician is properly trained. All needles used are single use only and pre-sterilized minimizing any risk of infection. 

I accept that at times acupuncture by the doctors will intentionally generate a local or spreading tingling, aching or other strong sensation. Manipulation, stretching, or exercise can result in some new stiffness or pain. Heat treatment of acupuncture points may, very rarely, leave a tiny burn. Cupping, scraping, bleeding or plum blossom hammer are therapeutic modalities that intentionally cause redness, bleeding or bruising, but I can refuse these modalities at any time. I know that herbs and supplements may cause strong 
allergic or other reactions, even though these reactions are very rare. I will always retain the right to accept or reject any diagnostic procedure or any treatment, before or during any procedure. 

I understand that in a community setting, other patients may overhear my conversation with the DOM and so will ask to discuss in private any issue that I have privacy concerns about. The doctors follow all confidentiality and privacy requirements of the medical professions. I will not disclose anything that I overhear in the course of anyone else's treatment. I also understand that although licensed as primary care practitioners in NM, the DOMs at Community Acupuncture Albuquerque are not providing primary care and I 
will take care of serious health concerns with my primary care provider. 

 I understand that no health care provider can ever guarantee results and that the time and number of treatments is not always predictable, but it is my expectation that the doctors will communicate their best estimates to me. I accept the fact that outcomes of treatment vary from no help to full resolution of symptoms, but more commonly, success will be defined as clearly perceivable improvement of my medical problem within a set number of treatments.

Terms And Conditions

I have read, understand and accept the Informed Consent, Cancellation and Privacy Policies above.

I have read, understand and accept the Terms & Conditions. The information in this form is correct to the best of my knowledge. *

Financial Policy

Please contact us by 8 am the day of your appointment to cancel. After that time and after the first instance, late cancellations will be charged at $15, no-shows at $20, unless there has been an emergency. 

There is no charge if you are refused due to COVID symptoms or circumstances.

Please note that we do not provide diagnostic or treatment codes which may be a requirement for your insurance company and we do not bill insurance companies directly but will provide a receipt.

Terms And Conditions

I have read, understand and accept the Financial Policy above.  I acknowledge understanding of the cancellation/no-show policy.

I have read, understand and accept the Terms & Conditions. The information in this form is correct to the best of my knowledge. *

Notice of Privacy Practices

This notice, and the accompanying Practices Regarding Disclosure of Patient Health Information, describe how health information about you may be used and disclosed, and how you can get access to your health information. Please review this information carefully.

Understanding your health record: A record is made each time you come for an Oriental medicine visit. Your symptoms, the practitioners judgments, and a plan of treatment are recorded. This record serves as a basis for planning your care and treatment at future visits, and also serves as a means of communication among other health professionals who may contribute to your care. Understanding what information is retained in your record and how that information may be used will assist you to ensure it is accurate and make informed decisions about who, what, when, where, and why others may be allowed access to your health information. 

Understanding your health information  rights: Your health record is the physical  property of Community Acupuncture  Albuquerque, but the content is about you,  and therefore belongs to you. You have the  right to review or obtain a paper copy of your  health record, and to request that appropriate  amendments be made to your health record.  You have the right to request restrictions on  certain uses and disclosures of your  information, to authorize disclosure of the  record to others, and be given an account of  those disclosures. Other than activity that has  already occurred, you may revoke any further authorizations to use or disclose your health  information. Should we need to contact you,  you have the right to request communication  by alternate means or to alternate locations.  

Our responsibilities: Community  Acupuncture Albuquerque is required to  maintain the privacy of your health  information and to provide you with this  notice of privacy practices. We are required  to follow the terms of this notice and to  notify you if we are unable to grant your  request to disclose or restrict disclosure of  your health information to others.  

Community Acupuncture Albuquerque  reserves the right to change these practices  and promises to make a good faith effort to  notify you of any changes. Other than for the  reasons described in this notice, we agree not  to use or disclose your health information  without your authorization.  

TO REPORT A PROBLEM, If you believe  your privacy rights have been violated, you  have the right to file a complaint with the NM  Board of Acupuncture and Oriental Medicine  and/or with the U.S. Secretary of Health and  Human Services with no fear of retaliation by  this office.

Practices Regarding Disclosure of Patient Health Information 

Your health information will be routinely used for treatment, and quality-monitoring, and your consent, or the opportunity to agree or object, is not required in these instances:  

- Treatment - Information obtained by your practitioner will be entered in your record and  used to plan the course of treatment. Your health information may be shared with others  involved in your care or providing consultation about your treatment. Your practitioners  own expectations and those of others involved in your care may also be recorded.  

- Quality Monitoring - The staff in this office will use your health information to assess the  care you received and compare your treatment outcome to others. Your information may be  reviewed for risk management or quality improvement purposes in our efforts to continually  improve the quality and effectiveness of the care and services we provide.  

In addition, the following disclosures are required by law and do not require your consent:  

- Food and Drug Administration (FDA) - This office is required by law to disclose health  information to the FDA related to any adverse effects of food, supplements, products, and  product defects for surveillance to enable product recalls, repairs, or replacements.  

- Worker"s Compensation - This office will release information to the extent authorized by  law in matters of workers compensation.  

- Public Health - This office is required by law to disclose health information to public  health and/or legal authorities charged with tracking reports of birth and morbidity. This  office is further required by law to report communicable disease, injury, or disability.  

- Law Enforcement - (1) Your health information will be disclosed in response to a valid  subpoena for law enforcement purposes, as required under state or federal law. (2) In the  event that a staff member or business associate of this office believes in good faith that one  or more patients, workers, or the general public are endangered due to suspected unlawful  conduct of a practitioner or violations of professional or clinical standards, provisions of  federal law permit the disclosure of your health information to appropriate health oversight  agencies, public health authorities, or attorneys.  

It is the Clinic"s practice to consider the following as routine uses and disclosures for which  specific authorization will not be requested. You have the right to request restrictions on these uses. Otherwise, the Clinic will request your authorization whenever disclosure of personal health  information is necessary to parties other than those referenced here.  

- Business Associates - Some or all of your health information may be subject to disclosure  through contracts for services to assist this clinic in providing health care. To protect your  health information, we require these Business Associates to follow the same standards held  by this office through terms detailed in a written agreement.

- Communications with Family - Using best judgment, a family member, close personal  friend identified by you, personal representative, or other persons responsible for your care  may be notified or given information about your care to assist them in enhancing your well being or to confirm your whereabouts.

Terms And Conditions

I have received a copy of the Notice of Privacy Practices and the Practices Regarding Disclosure of Patient Health Information. I understand my health information will be used and disclosed consistent with these Notices.

I have read, understand and accept the Terms & Conditions. The information in this form is correct to the best of my knowledge. *